Barriers and facilitators to integrate oral health care for older adults in general (basic) care in East Netherlands. Part 1: Normative integration.

OBJECTIVE: to synthesise a framework of barriers and facilitators in the normative integration of oral health care (OHC) into general health care for frail older adults at macro (system), meso (organisation and interprofessional integration) and micro (clinical practice) levels. BACKGROUND: Identification of these barriers and facilitators is expected to promote better and more appropriate care. METHODS: For this qualitative study, comprising 41 participants, representatives of 10 different groups of (professional) care providers, and OHC receivers (home-dwelling, and nursing home patients) in East Netherlands were interviewed. Transcripts of the in-depth, topic-guided interviews were thematically analysed. In a subsequent workshop with 52 stakeholders, results and interpretations were discussed and refined. RESULTS: Two main themes were identified: (1) a compartmentalised care culture in which OHC and general health care are seen as two separate realms, and (2) prioritisation, awareness and attitude regarding OHC integration. Subthemes such as low political attention (macro level); unclear responsibilities, hierarchical relations and the lack of vision of organisations (meso level); and poor awareness and low prioritisation by care providers and patients (micro level) were identified as potential barriers. Subthemes such as leadership (meso level), and the supportive personality of individual caregivers and ownership of patients (micro level) were identified as facilitators. CONCLUSION: Barriers and facilitators in normative OHC integration in The Netherlands are interrelated and apparent at macro-, meso- and micro levels. They are mainly related to (a) a compartmentalised care culture, and (b) related low prioritisation, and poor awareness of and attitude towards (integration of) oral health (care).

Food avoidance is associated with reduced dentitions and edentulousness.

OBJECTIVES: To investigate associations between food avoidance and dental status, age, gender, and socio-economic status (SES). MATERIALS AND METHODS: The Chinese sample comprised 1463 dentulous (≥ 1 tooth in each jaw) and 124 edentulous (in one or both jaws) participants aged ≥ 40 yrs. The Vietnamese sample comprised 2820 dentulous and 253 edentulous participants aged ≥ 20 yrs. Food avoidance due to chewing difficulties was scored for regionally common 4 soft and 4 hard foods. Dental status was classified according to the multi-level hierarchical dental functional classification system (HDFC) based on the number and location of teeth and posterior occlusal pairs. Associations were analyzed using multivariate logistic regression analyses. RESULTS: For dentulous participants, the chance of avoiding foods was significantly larger with < 10 teeth in each jaw (OR = 2.26 (Chinese sample), respectively 1.74 (Vietnamese sample)), incomplete anterior region (OR = 1.78, respectively 1.84), "impaired" premolar region (OR = 2.22, respectively 1.71), or "impaired" molar region (OR = 2.46, respectively 1.84). Edentulous participants had twice the chance of avoiding foods (OR = 2.01 respectively 2.20). Avoiding foods was significantly associated with higher age. Participants of low SES (Chinese sample, OR = 1.93) and females (Vietnamese sample, OR = 1.27) had a larger chance of avoiding foods. CONCLUSIONS: Avoiding foods was significantly associated with reduced dentitions, edentulousness, and higher age; low SES only in the Chinese and being female only in the Vietnamese sample. CLINICAL RELEVANCE: Incomplete anterior regions, "impaired" premolar or molar regions, and especially edentulousness can be considered significant risk indicators for food avoidance.

Oral health care behavior and frailty-related factors in a care-dependent older population.

OBJECTIVES: To assess, in older people with different levels of care-dependency 1) which frailty- and non-frailty related predisposing, enabling and need factors are associated with a) dental service use (DSU) frequency, b) changed DSU after the onset of care-dependency, c) brushing frequency, and d) changed brushing frequency since the onset of care-dependency; and 2) if unfavorable oral health care behavior is related to unfavorable oral health outcomes. METHODS: Bivariate analyses and multivariable logistic regression analyses were performed to evaluate data from 126 Dutch care-dependent people aged≥65 on oral and general health, psychological and social issues. RESULTS: Lower DSU frequency was mainly related to non-frailty-related predisposing factors, especially being edentate (OR=3.75; CI: 1.20-11.71; p=0.023) and lower socioeconomic status (OR=1.74; CI: 0.97-3.14; p=0.065); lower DSU frequency since the onset of care-dependency to frailty-related enabling and need factors, especially 'difficulty going to the dentist' (OR=4.98; CI:1.85-13.36; p=0.001) and clinically assessed treatment need (OR=3.23; CI:1.24-8.42; p=0.016); lower brushing and changed (reduced) brushing frequency to frailty-related enabling factors, and, in case of reduced frequency, significantly to 'not being capable of summoning the effort to brush' (OR=8.28; CI: 1.44-47.56; p=0.018) and high care-dependency level (OR=4.14; CI: 1.05-16.36; p=0.043). Elders with lower and especially those with reduced DSU and brushing frequencies since the onset of care-dependency, had generally worse oral health outcomes and related quality of life. CONCLUSIONS: Oral health care behavior, especially lower brushing and DSU frequency since the onset of care-dependency, is related to specific frailty-related factors in a care-dependent older population. CLINICAL SIGNIFICANCE: Oral care-providers should be alert to the role of specific frailty-related factors, which are likely to reduce DSU and brushing frequency in the course of increasing frailty.

Oral health-related quality of life and associated factors in a care-dependent and a care-independent older population.

OBJECTIVES: To examine relationships between oral health (OH) factors and general health (GH) factors (including physical, mental, and social health domains), and oral health-related quality of life (OHRQoL) in a care-independent and a care-dependent older population. METHODS: Care-independent participants (n=109) were recruited from the Nijmegen dental school; care-dependent participants (n=126) from residential aged care facilities. Data collected included: OHRQoL (Geriatric Oral Health Assessment Index (GOHAI)), age, gender, socioeconomic status, number of teeth and occluding pairs, presence of carious teeth, presence of removable dental prostheses, clinically assessed treatment need (CTN), self-reported GH, and, only for care-dependent participants: care-dependency level and health domain variables: physical, mental (SF-12: Physical and Mental Component Summary scores), and social (ENRICHD social support index). Multiple linear regression analyses were performed to assess the associations with GOHAI scores. RESULTS: Mean GOHAI scores of care-independent (51.6±7.4) and care-dependent participants (52.1±6.7) did not differ significantly despite considerably worse OH status of the latter. Regression models revealed significant (p≤0.05) associations between GOHAI scores and age, prosthodontic status, and CTN in care-independent participants (R2=0.19) and only with CTN in care-dependent participants. (R2=0.09). Self-reported GH was not significantly associated with GOHAI; when substituted by the health domain variables, only social support was significantly associated with GOHAI scores. CONCLUSIONS: GOHAI outcomes are associated with different variables in care-independent and care-dependent older subjects. In care-dependent subjects, GOHAI outcomes are more strongly related to social support than to OH factors or other GH factors. CLINICAL SIGNIFICANCE: OHRQoL outcomes should not be compared across care-dependent and care-independent populations without careful interpretation of these outcomes against specific factors that distinguish such populations, like health factors and living environment.

Validation of a Dutch version of the Geriatric Oral Health Assessment Index (GOHAI-NL) in care-dependent and care-independent older people.

BACKGROUND: The GOHAI is a frequently used instrument to measure oral health-related quality of life (OHRQoL) of adults, in particular older people. The aim of this study was to translate the original English version of the GOHAI into a Dutch version (GOHAI-NL), and to test the validity and reliability of the GOHAI-NL in care-independent and care-dependent older people. METHODS: The GOHAI questionnaire was translated into Dutch, discussed by an expert panel, back-translated to the original, pilot-tested and assessed for cognitive and conceptual equivalence. The resulting GOHAI-NL was tested in a groups of care-independent (Group A, n = 109, mean age 73.1 ± 5.4 years) and care-dependent (Group B, n = 118, mean age 85.6 ± 7.0. years) cognitively alert people of 65 years and over. Psychometric properties including reliability (internal consistency, item-total, item-dimension, dimension-total, inter-item correlation, and test-retest stability), and validity (convergent, discriminant, known-group), and floor and ceiling effects were assessed. RESULTS: Internal consistency was confirmed by Cronbach's alphas of 0.86 (group A) and 0.80 (group B). Item-total score correlations were between 0.4 and 0.7 except for item 3 in group A (0.34) and B (0.08) and for item 12 in group A (0.20). Item-dimension and dimension-total correlations were between 0.30 and 0.78 and around 0.7 respectively for the dimensions 'physical functioning' and 'psychosocial functioning', but lower for the dimension 'pain and discomfort' with item-dimension correlations between 0.13 and 0.44. Average inter-item correlations were 0.34 ± 0.11 (group A) and 0.33 ± 0.08 (group B). Test-retest correlation of the total score (GOHAI-ADD) was 0.88 in group A (ICCs: 0.62 - 0.88) and 0.93 in group B (ICCs: 0.64 - 0.91). Significant correlations in the expected direction were found between GOHAI and most oral health-related variables except for presence of caries in group A, and perceived general health, prosthodontic status and number of natural teeth in group B. No floor or ceiling effects were detected at GOHAI-ADD level; however ceiling effects did occur at dimension level. CONCLUSION: The GOHAI-NL has satisfactory reliability and validity and can be used to measure OHRQoL in Dutch care-dependent and care-independent older people.

The impact of frailty on oral care behavior of older people: a qualitative study.

BACKGROUND: Frailty has been demonstrated to negatively influence dental service-use and oral self-care behavior of older people. The aim of this study was to explore how the type and level of frailty affect the dental service-use and oral self-care behavior of frail older people. METHODS: We conducted a qualitative study through 51 open interviews with elders of varying frailty in the East-Netherlands, and used a thematic analysis to code transcripts, discussions and reviews of the attributes and meaning of the themes to the point of consensus among the researchers. RESULTS: Three major themes and five sub-themes emerged from our analyses. The major themes indicate that frail elders: A) favor long-established oral hygiene routines to sustain a sense of self-worth; B) discontinue oral hygiene routines when burdened by severe health complaints, in particular chronic pain, low morale and low energy; and C) experience psychological and social barriers to oral health care when institutionalized. The subthemes associated with the discontinuation of oral care suggest that the elders accept more oral pain or discomfort because they: B1) lack belief in the results of dental visits and tooth cleaning; B2) trivialize oral health and oral care in the general context of their impaired health and old age; and B3) consciously use their sparse energy for priorities other than oral healthcare. Institutionalized elderly often discontinue oral care because of C1) disorientation and C2) inconveniencing social supports. CONCLUSION: The level and type of frailty influences people's perspectives on oral health and related behaviors. Frail elders associate oral hygiene with self-worth, but readily abandon visits to a dentist unless they feel that a dentist can relieve specific problems. When interpreted according to the Motivational Theory of Life Span Development, discontinuation of oral care by frail elderly could be viewed as a manifestation of adaptive development. Simple measures aimed at recognizing indicators for poor oral care behavior, and providing appropriate information and support, are discussed.

The impact of having natural teeth on the QoL of frail dentulous older people. A qualitative study.

BACKGROUND: In order to adapt oral care and treatment to the demands of the growing group of frail dentulous older people, it is important to understand how and to which extent having natural teeth contributes to the quality of life (QoL) of frail older people and how frailty influences their perspective. METHODS: A qualitative approach was used. Interviews with 38 Dutch frail older dentulous people were tape-recorded, transcribed, coded for content and analyzed. Additional information was collected which included age, gender, living situation, use of dental prostheses, self-reported oral health status, chronic disorders, and an index for frailty. RESULTS: Seven themes were identified in the relationship between natural teeth and the QoL of the participants: pride and achievement; intactness; sense of control; oral function; appearance; comfort; along with coping and adapting to disabilities. Having natural teeth generally had a positive effect on QoL. Positive effects through pride and achievement, intactness, and sense of control were most apparent for the most severely frail. They compared themselves with peers who are more often edentate, and valued the good state of their teeth against the background of their declining health, especially those with disabilities causing severe chronic pain or impaired fine-motor skills. The effect of coping with and adaptation to tooth loss was also most apparent for the most severely frail. There was a gender effect in that the men generally cared less about having natural teeth than women, regardless of their level of frailty. CONCLUSIONS: QoL of frail older people is positively influenced by natural teeth, and this effect seems to increase with increasing frailty. Preservation of teeth contributes to a positive body image and self-worth. Oral care for frail people should aim to preserve natural teeth if possible.